Anas Gremida

Duodenitis, Diarrhea, and Death in a Patient with AIDS

A 47-year-old Native American male was initially evaluated in the emergency room with a 4-month history of diarrhea, which was described as voluminous, foul smelling, and occurring 3–6 times daily, both day and night. It was associated with diminished oral intake, lassitude, anorexia, and an unintentional weight loss of 42 lb over the past year. His roommate additionally reported that, following the diagnosis of infection with human immunodeficiency virus (HIV), the patient had become disoriented, forgetful, and anhedonic. The patient’s HIV infection was diagnosed 8 months prior to this presentation. At the time of diagnosis, he was diagnosed with pneumococcal pneumonia and hairy leukoplakia as complications of the acquired immune deficiency syndrome (AIDS). The major risk factor was having unprotected sex with men. The patient’s cluster of differentiation (CD)4 count at the time of diagnosis was 12 cells/mm3, and his viral load was 271,000 copies/ml. After hospital discharge, he established care at the HIV clinic and was started on antiretroviral therapy with dolutegravir (tenofovir alafenamide fumarate and emtricitabine), in addition to azithromycin and sulfamethoxazole–trimethoprim as prophylaxis for opportunistic infection. Two months after starting therapy, the patient’s CD4 count had improved to 98 cells/mm3 and his viral count had dropped to 6.2 copies/ml. Nonetheless, due to his depression and lack of social support, the patient did not rigidly adhere to his prescribed medications and his CD4 count and viral load fluctuated throughout the course of his disease. Physical examination revealed a cachectic male, with a temperature of 36.8 degrees Celsius, a heart rate of 87/min, a blood pressure of 96/45 mmHg, and a respiratory rate of 16/ min. On physical examination, he had pale conjunctivae and florid white thrush plaques on his tongue and hard palate, consistent with the diagnosis of oral candidiasis. Hs lungs were clear, and heart sounds were normal. Examination showed a scaphoid abdomen, with normal bowel sounds, and no abdominal tenderness; the liver was palpable although the liver span was within normal limits. The spleen was palpable only on deep inspiration (Castell’s sign). There were enlarged, non-tender, and rubbery lymph nodes in the cervical and inguinal areas. He had no penile or perianal lesions. There was diffuse decubitus erythema on his back that did not blanch: There was no skin ulceration. Neuromuscular examination showed sarcopenia in the proximal muscles, but was otherwise unremarkable. Laboratory studies (with normal ranges) revealed a white blood cell count of 2700/mm3 (4000–11,000/mm3), hematocrit of 25% (36–48%), platelet count of 231,000/ mm3 (150,000–400,000/mm3), and serum concentrations of sodium 143 mmol/l (137–145 mmol/l), potassium 2.6 mmol/l (3.4–4.8 mmol/l), chloride 115 mmol/l (98–107 mmol/l), magnesium 2.5 mg/dl (1.6–2.3 mg/ dl) bicarbonate 18 mmol/l (20–31 mmol/l), creatinine 1.07 mg/dl (0.66–1.25 mg/dl), and random glucose 63 mg/ dl (74–140 mg/dl). Liver function tests showed serum concentrations of total protein of 5.1 g/dl (6.3–8.5 g/dl), albumin 1.3 g/dl (3.5–5.0 g/dl), alkaline phosphatase 143 U/l (38–126 U/l), aspartate aminotransferase 19 U/l (17–59 U/l), alanine aminotransferase 13 U/l (21–72 U/l), and total bilirubin 0.6 mg/dl (0.2–1.3 mg/dl); serum thyroid stimulating hormone (TSH) was 0.9 mg/dl (normal 0.5–3.5 mg/dl). Stool osmolar gap was calculated at 78 mosm/kg (normal 50–100 mosm/kg), and qualitative fecal fat was elevated. * Anas Gremida agremida@salud.unm.edu

Hemolysis in Alcoholic Liver Disease: Zieve’s Syndrome

A 46-year-old female with history of asthma, hyperlipidemia, and heavy alcohol intake was initially evaluated for the complaint of abdominal pain for 1 week, described as generalized, aching, constant, nonradiating, and associated with lassitude, nausea, vomiting, and diminished appetite. She also noticed darkening of her urine over the same time. The patient denied any overt upper or lower gastrointestinal bleeding and reported no changes in her mental status. The patient had consumed about 1 pint of vodka daily for the past 8 years. She reported that her last alcoholic beverage was taken 3 days prior to admission. She denied illicit drug use. On examination, she looked jaundiced, with scleral icterus and conjunctival pallor. There were multiple chest telangiectasia within the distribution of the superior vena cava. Physical examination revealed a slightly distended abdomen with mild generalized tenderness. The liver span was 16 cm and was mildly tender to direct palpation; Murphy’s sign was negative. The spleen was not palpable, but there was dullness on percussion in the ninth intercostal space on deep inspiration, anterior to the mid-axillary line (a positive Castell’s sign). The flanks were full but there was no shifting dullness or fluid wave. Bowel sounds were normal. Laboratory tests showed: hematocrit 22% (36–48%), hemoglobin 7.1 g/dl (12–14 g/dl), mean corpuscular volume 115 fl (80–101 fl), reticulocyte count 11% (0.5–1.5%), platelets 165,000/mm3 (150,000–400,000/mm3), with serum concentrations of aspartate aminotransferase 118 U/l (17–59 U/l), alanine aminotransferase 82 U/l (17–59 U/l), total bilirubin 12 mg/dl (0.2–1.3 mg/dl), indirect bilirubin 10.0 mg/dl, lactate dehydrogenase 400 U/l (100–190 U/l), lipase 285 mg/dl (10–73 mg/dl), triglycerides 208 mg/dl (< 150 mg/dl), cholesterol 275 mg/dl ethanol 65 mg/dl, and direct anti-globulin test (Coombs test) was negative. Serum haptoglobin was undetectable (20–240 mg/dl), and international normalized ratio (INR) was 1.7 (0.5–1.1). A peripheral blood smear showed spur cells, schistocytes, and prominent macrocytosis. A stool test was negative for occult blood. Abdominal ultrasound with Doppler flow measurement showed patent vasculature, increased liver echogenicity, enlarged spleen, and minimal ascites. The patient was diagnosed with Zieve’s syndrome (hemolytic anemia associated with alcoholic liver disease) and was provided supportive management with intravenous hydration, thiamine supplementation, and management of alcohol withdrawal. The patient recovered and was discharged home after 5 days. The serum aminotransferases and bilirubin concentrations fell gradually during the hospital stay (Figs. 1, 2). The patient had addiction counseling before discharge, and hospital follow-up was arranged in the liver disease clinic and in an outpatient rehabilitation program.

Colitis and Pancreatitis in a Patient with Systemic Lupus Erythematosus: Due to Disease or to Drug?

A 37-year-old female with a history of developmental delay, left-sided focal epilepsy due to polymicrogyria, systemic lupus erythematosus (SLE), and stage 3 chronic kidney disease due to lupus nephritis was initially evaluated for diarrhea of 4 months duration. Due to the presence of cognitive issues, her history was obtained from her mother, her primary caregiver. She reported that her daughter had been having 5–6 loose bowel movements per day for 4 months, associated with a weight loss of 15 lbs over this time period, contrasting with the one formed bowel movement per day she had experienced prior to the onset of diarrhea. Moreover, she was stated to have had sharp epigastric pain and intermittent nausea and vomiting for 3 days prior to evaluation and was currently not able to tolerate any oral intake. The patient was hospitalized 1 month prior to the current admission and diagnosed with influenza B. At that time, she was neutropenic with a white blood cell count of 0.7 × 109/dl (4.5–11.0 × 109/dl) which on consultation with the hematology service was attributed to her acute viral infection. She was treated with oseltamivir and given one dose of filgrastim prior to hospital discharge. Other past medical history included hypertension, hypothyroidism, and avascular necrosis of the femur due to chronic steroid use. In her family history, her mother and father had diabetes. She denied any history of smoking, alcohol, or illicit drug use. Her lupus nephritis had been treated with mycophenolate mofetil (MMF) for over 2 years, but 2 months prior to admission this treatment was changed to mycophenolate sodium (MPS) by her rheumatologist who thought MMF might have caused her diarrhea. Since the medication switch did not relieve the diarrhea, she presented to the Emergency Department, where she was afebrile and tachycardic (115/min), with a blood pressure of 70/42 mm Hg and respiratory rate 18/ min with oxygen saturation of 100% on room air per pulse oximetry. Physical examination revealed signs of marked intravascular volume depletion with a dry oral mucosa; abdominal examination revealed hyperactive bowel sounds and tenderness to palpation in the epigastric and periumbilical regions, but no rebound tenderness. Rectal examination was unremarkable. Laboratory tests on admission showed a blood hemoglobin of 10.1 g/dl (12-16 g/dl), a white blood cell count—3.4 × 109 per liter (4.5–11.0 × 109 per liter), a platelet count—150,000 mm3 (150,000–400,000/mm3), and serum concentrations of sodium—129 mmol/L (134144 mmol/L), potassium—3.5 mmol/L (3.5–5 mmol/L), chloride—98 mmol/L (98–111 mmol/L), bicarbonate—10 mmol/L (20–30 mmol/L), BUN—52 mg/dl (7–31 mg/dl), creatinine-3.81 mg/dl (baseline 0.7–0.9 mg/ dl), and lipase—479 mg/dl (10–73 mg/dl); liver function tests were normal. A computerized tomographic (CT) scan of the abdomen performed on admission showed findings suggestive of acute pancreatitis and a hydropic gall bladder. An ultrasound scan of the abdomen showed a dilated gall bladder but no evidence of the presence of cholelithiasis or choledocholithiasis. The patient was aggressively resuscitated with intravenous fluids followed by improvement in her blood pressure, heart rate, electrolyte abnormalities, and kidney function. Other tests included stool culture, * Swathi Paleti spaleti@salud.unm.edu

Acute Pancreatitis: Nothing to SPiT At.

An 18-year-old female patient was initially evaluated for a 3-day history of worsening epigastric pain, nausea, and vomiting. She had no known medical problems and no history of alcohol consumption, cigarette smoking, or marijuana use. Her only medication was levonorgesterol/ ethinyl estradiol for birth control. Physical examination revealed blood pressure 110/65 mmHg, pulse 91/min, temperature 36.6 C, and respiratory rate 16/min. Cardiopulmonary examination showed normal heart sounds and clear breath sounds. Abdominal examination revealed a flat abdomen with normal bowel sounds, dullness on percussion all over the abdomen, and tenderness on palpation of the epigastrium with local guarding but no rebound tenderness. Murphy’s and Carnett’s signs were negative. Complete blood count, metabolic panel, and liver function laboratory testing were normal with the exception of an elevated serum lipase (8369 U/L; normal range 12–70 U/L). Computed tomography (CT) of the abdomen (with intravenous contrast) revealed a 7 cm 9 9 cm 9 9 cm well-defined mass in the head of the pancreas (Fig. 1a). Magnetic resonance cholangiopancreatography (MRCP) demonstrated a complex cystic mass in the head of the pancreas with wall thickening that enhanced with contrast suggestive of a solid pseudopapillary tumor (SPT) (Fig. 1b). Based on these findings, an endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) of the mass was performed, which revealed loose clusters of monotonous atypical cells with finely granular cytoplasm that formed papillary structures (Fig. 2). Immunohistochemical staining was positive for nuclear b-catenin (Fig. 3a), cluster of differentiation marker 10 (CD10) (Fig. 3b), estrogen (Fig. 3c), and progesterone receptors (Fig. 3d). Based on these findings, a diagnosis of an SPT of the pancreas was made. Staging CT scans showed no evidence of metastasis. The acute pancreatitis was managed conservatively with fluid replacement using crystalloid solution (0.9% NaCl) at a rate of 8 mL/kg, and the pain was controlled by fentanyl using a patient-controlled pump. The patient fully recovered and was discharged home on the fourth hospital day. Two weeks later, the patient underwent an uneventful laparascopic pancreaticoduodenectomy, from which she fully recovered.

Hepatic Dysfunction in Renal Cell Carcinoma: Not What You Think?

A 55-year-old Caucasian male, with history of type 2 diabetes mellitus and benign prostatic hyperplasia, was initially evaluated in emergency department with a 2-month history of worsening jaundice, pruritus, and right upper quadrant abdominal pain. His gallbladder had previously been removed. Medications included insulin and tamsulosin. He had a 20 pack-year history of smoking. He denied ever drinking alcohol to excess or using illicit drugs. On presentation, his vital signs were within normal limits. Physical examination revealed only scleral icterus, diffuse skin excoriations on the extremities and torso, and abdominal tenderness to palpation over the right upper quadrant. The liver span was normal; the spleen was not enlarged, and there was no lymphadenopathy or peripheral edema. Results of laboratory tests showed a hemoglobin (Hgb) 18 g/dl (13–17 g/dl), white blood cell (WBC) count 10 K/ mm (4–10 K/mm), platelet count 300 K/mm (150–400 K/mm), blood urea nitrogen (BUN) 20 mg/dl (8–21 mg/dl), and serum concentrations of creatinine 1.0 mg/dl (0.8–1.3 mg/dl), total bilirubin 20.9 mg/dl (0.3–1.9 mg/dl) [(conjugated bilirubin 12.5 mg/dl)], alkaline phosphatase (ALP) 327 units/l (50–100 units/l), gamma glutamyl transpeptidase (GGTP) 185 units/l (6–50 units/l), prothrombin international normalized ratio (INR) 1.6 (0.9–1.2), albumin 2.5 g/dl (3.5–5.5 g/dl), aspartate aminotransferase (AST) 29 units/l (5–30 units/l), and alanine aminotransferase (ALT) 34 units/l (5–30 units/l). Urinalysis was positive for urobilinogen and glucose, with 1 red blood cell/hpf on microscopic examination. Although an ultrasound examination of the right upper quadrant was unremarkable, abdominal computed tomography (CT) using intravenous contrast revealed an enhancing, 2.5 cm diameter, exophytic mass arising from the lower pole of the left kidney (Fig. 1). Magnetic resonance cholangiopancreatography (MRCP) was normal. The patient first underwent an ultrasound-guided liver biopsy, which revealed portal and periportal neutrophilic inflammatory infiltrates, with bile duct and ductular proliferation and centrilobular zone v3 hepato-canalicular cholestasis, findings consistent with cholestatic hepatitis. Serum concentrations of liver enzymes were unchanged during the entire hospitalization. Under the direction of the genitourinary surgical service, the patient underwent uneventful surgical resection of the renal mass. Histologic examination of the mass revealed the presence of tumor, a clear cell renal carcinoma with no vascular or capsular invasion. No obvious metastases were present, and the liver appeared grossly normal. Three months post-nephrectomy, serum concentrations of liver tests had returned to within normal limits (Fig. 2).

Dyspepsia, Diarrhea, and Deafness: Some Calling Cards of the Great Mimic!

A 29-year-old homosexual male with no previous medical history was initially evaluated for nausea, vomiting, diarrhea, and weight loss. The patient’s symptoms started six months prior to presentation with watery diarrhea, 4–10 low-volume, and non-bloody bowel movements per day, associated with tenesmus and unintentional weight loss of 40 lb over the six-month period. A month before presentation, the patient had developed aching epigastric pain that was episodic, exacerbated by eating and was associated with postprandial nausea and vomiting * 10 min after food ingestion. The patient also reported that he started to experience diminished hearing in his left ear over the previous month. The patient was not taking any medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), but he smoked one marijuana cigarette 2–3 times per week for about a year. The patient is in a monogamous relationship with a male partner who is infected with human immunodeficiency virus (HIV) and admitted to having unprotected sex with him on a number of occasions. Although the exact HIV status and cluster of differentiation (CD)4 count of his partner was not known to the patient, he knew that his partner was receiving antiretroviral therapy. There was no history of recent travel or contact with animals. Family history was significant only for Crohn’s disease in his mother. Physical examination was generally unremarkable with no icterus or skin changes. Pertinent findings included an axillary temperature of 36.1 C, heart rate 90/min, blood pressure 122/87 mmHg, and respiratory rate of 16/min. Examination of his abdomen revealed mild localized epigastric tenderness on direct palpation, but no rebound tenderness. He had no hepatosplenomegaly or other masses. Bowel sounds were active, but there was no distension or ascites. There were no enlarged lymph nodes. There were no penile, perianal, or mucous membrane lesions. Neurologic, audiologic, and ophthalmic examinations were unremarkable. Laboratory studies (normal ranges) revealed a white blood cell count of 7100/mm (4000–11,000/mm, hematocrit of 43.4% (36–48%), platelet count of 363,000/mm (150,000–400,000/mm), and serum concentrations of sodium 141 mmol/L (137–145 mmol/L), potassium 4.0 mmol/L (3.4–4.8 mmol/L), chloride 99 mmol/L (98–107 mmol/L), magnesium 2.1 mg/dL (1.6–2.3 mg/ dL), bicarbonate 27 mmol/L (20–31 mmol/L), creatinine 0.86 mg/dL (0.66–1.25 mg/dL), and random glucose 105 mg/dL (74–140 mg/dL). Liver function tests showed a total serum protein of 8.8 g/dL (6.3–8.5 g/dL), albumin 4.4 g/dL (3.5–5.0 g/dL), alkaline phosphatase 108 U/L (38–126 U/L), aspartate aminotransferase 34 U/L (17–59 U/L), alanine aminotransferase 40 U/L (21–72 U/L), total bilirubin 0.7 mg/dL (0.2–1.3 mg/dL), and lipase 49 U/L (21–72 U/L). Other laboratory studies including Clostridium difficile toxin gene polymerase chain reaction (PCR) assay, enzyme-linked immunosorbent assay (ELISA) for Giardia antigen, anti-tissue transglutaminase antibody, fecal lactoferrin, fecal H. pylori antigen, stool bacterial & Anas Gremida agremida@salud.unm.edu

A Fairy Tale with a Hairy Tail

A 21-year-old pregnant female at 33 weeks of gestation suffering from bipolar disorder was referred from a local hospital for management of abdominal pain that started 10 days prior to presentation. The pain was localized in the epigastrium, aching, constant, non-radiating, of moderate intensity and associated with loss of appetite. Two days before presentation, the patient had developed intractable nausea and non-bloody, non-bilious emesis (Figs. 1, 2). Physical examination revealed patchy alopecia, displaying cephalic broken hair shafts of variable length. Some fractured hairs were coiled in a shape resembling the ‘‘question mark sign,’’ a finding suggestive of trichotillomania. The patient was wearing a wig. Abdominal examination revealed mild epigastric tenderness when palpated directly, but was otherwise normal. Murphy’s sign was negative. The fetus was in a cephalic presentation with the fundus located 2 cm below the xiphoid process. Moving fetal parts were felt intermittently. Vaginal examination by the obstetric staff revealed a closed cervix with no bleeding, considered normal for her stage of pregnancy. Fetal assessment showed a viable fetus with 135 bpm with no decelerations. Abdominal ultrasound showed a normal placenta with no evidence of placental abruption. Results of laboratory tests (with normal ranges) were as follows: white blood cell count 7 K (4–11 K/mm), hemoglobin 9.7 g/dl (12–14 g/dl), hematocrit 33% (36–48%), MCV 75 fl/rbc (81–101 fl/rbc), ferritin 19 (18–160 ng/ml), platelet count 245,000/mm (150,000–400,000/mm), serum concentrations of sodium 142 mmol/L (137–145 mmol/l), potassium 3.5 mmol/l (3.4–4.8 mmol/L), chloride 109 mmol/L (98–107 mmol/l), magnesium 2.1 mg/dl (1.6–2.3 mg/dl), bicarbonate 20 mmol/l (20–31 mmol/l), creatinine 0.72 mg/dl (0.66–1.25 mg/dl), and glucose (random) 100 mg/dl (74–140 mg/dl). Liver function tests showed total serum concentrations of protein of 7 g/dl (6.3–8.5 g/dl), albumin 3.1 g/dl (3.5–5.0 g/dl), alkaline phosphatase 124 U/L (38–126 U/l), aspartate aminotransferase 16 U/l (17–59 U/L), alanine aminotransferase 11 U/l (21–72 U/l), total bilirubin 0.4 mg/dl (0.2–1.3 mg/dl), and lipase 91 U/L (21–72 U/l). Fecal occult blood tests were negative. Given a high level of suspicion of the presence of a trichobezoar, the patient underwent an upper gastrointestinal endoscopy that revealed a large ball of hair (bezoar) occupying about half of the gastric cavity and extending through the pylorus into the duodenum. The bezoar was pulled into the gastric cavity and, using raptor forceps and an endoscopic overtube, was gradually removed in pieces. The remaining concretions were removed using a Roth net. Duodenal biopsies were normal. On the following day, the patient’s symptoms resolved completely and she was able to tolerate a normal diet. She underwent psychiatric evaluation in the hospital and was scheduled for additional therapy by the psychiatry service and by her primary care physician for management of her anemia. & Anas Gremida agremida@salud.unm.edu

White Bile in Malignant Biliary Obstruction: A Poor Prognostic Marker

A 71-year-old man presented with progressively worsening painless jaundice. Laboratory findings were significant for severe cholestasis (serum total bilirubin, 24 mg/dL; direct bilirubin, 22 mg/dL). Computed tomography of the abdomen revealed a 4-cm mass in the head of the pancreas with marked extraand intra-hepatic biliary dilatation (Fig. 1A). Diffuse hepatic metastases and extensive metastatic retroperitoneal and left supraclavicular adenopathy were also noted (Fig. 1B). Endoscopic ultrasound (EUS) revealed a 32×28 mm hypoechoic heterogeneous solid mass in the head of the pancreas, causing complete obstruction of the common bile duct, with marked upstream ductal dilation (Fig. 2A). EUS-guided fine needle aspiration cytology revealed a poorly differentiated pancreatic adenocarcinoma. Endoscopic retrograde cholangiopancreatography for transpapillary biliary stenting was unsuccessful. Subsequently, EUS-guided choledochoduodenostomy using a 15–10 mm, cautery-tipped, biflanged, fully covered, lumen-apposing